How a medical pioneer’s cocaine addiction helped shape modern residency programs

Hundreds of medical school graduates, donning their hard-earned white coats, begin their residencies each summer, during which they spend at least a few more years training in a specialty area such as surgery or pediatrics before receiving a license to practice.

Residency is known as a rigorous learning and work environment, where new doctors advance to take on greater responsibilities under the guidance and supervision of attending physicians.

Two researchers at the University of Calgary believe the program’s structure may be linked to the man who revolutionized medical training in North America, William Stewart Halsted – and his cocaine addiction.

Considered a pioneer of modern surgery, the American surgeon is credited with numerous advancements in the field, from improving radical mastectomy surgery for breast cancer to the invention of surgical gloves.

One of his contributions to the practice of medicine: a new residency training model that he developed at the prestigious Johns Hopkins Hospital in Baltimore, MD, in the late 1800s.

The program, characterized by a tiered system in which residents were ranked by seniority and given hierarchical responsibility, may have been designed by Halsted as a way to help him hide his addiction and his own deteriorating speed and accuracy. a search In Canadian Journal of Surgery.

“He brought in all these young students who wanted to be surgeons. He set it up (as a training program), but really he was supporting them,” said Dr. Norman Schechter, professor emeritus at the University of Calgary’s Cumming School of Medicine and co-author of the study.

“He started a system where he could weed out the best people out of a pyramid structure, where he became the ‘senior resident’ by picking the person who was the most skilled and the smartest. And then he said, ‘You come with me (to the operating room). Even better, you start over, and I’ll catch you.’

“Much of the design of the residency program was largely self-serving because it basically provided (Halsted) a way to not have a lot of contact with patients, yet still provide high-quality surgery,” said James Wright, co-author and professor emeritus at the University of Calgary’s Cumming School of Medicine.

From experimentation to addiction

Halsted began his career in New York, where he regularly experimented with procedures such as blood transfusions, pushing the boundaries of medical knowledge at the time.

But an experiment in 1884 went much further.

Then 32-year-old Halsted received a report that mentioned a possible new local anesthetic: cocaine.

Experimenting on himself with the drug, Halsted became addicted and his career as a young surgeon rapidly declined as he went in and out of treatment facilities.

To treat his cocaine addiction, Halsted was given morphine, to which he also became addicted.

Halsted’s addiction ultimately ruined his career in New York, but also marked the beginning of his work at Johns Hopkins, where he transitioned into medicine.

The study states that after Halsted’s experimentation with cocaine, his surgical style changed from bold and fast to “a more reflective, anatomical style, in which preservation of tissue and blood was more important than speed” – and achieved better results.

William Mayo, the late American surgeon and co-founder of the famed Mayo Clinic, reportedly remarked upon watching Halsted perform surgery, “I have never seen a wound operated on from above when the lower part has already healed.”

While there is no clear record of how Halsted’s addiction shaped his training model, Schechter said that reading “between the lines” of the historical record (including published quotes from Halsted, the writings of his former trainees and other surgical scholars, and Gerald Imber’s book) Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted) Researchers can conclude that it indeed played a factor.

A new style of medical training

Before Halsted, doctors were trained using an apprenticeship training model, in contrast to his residency program which provided a more structured educational approach based on the German training model he admired.

According to Wright, the surgeon’s formal program divided training doctors into several levels, a pyramid structure that included entry with a senior role and “intense competition” for mid-level positions and advancement.

“He didn’t have the true surgical skills because of his addiction, but he still had the intelligence to perform surgery. And so it seemed like this… would be a really good way to hide someone’s addiction and still provide excellent service, because you have this cadre of residents who are trying to impress the professor,” Wright said.

Dr. Frank Stanish, a historian of medicine and health care at the University of Calgary, said that Schechter and Wright correctly pointed out that “residents and assistants had a central and essential place in the entire Halsted system, namely supporting their masters.”

Halsted’s program would go on to produce medical pioneers such as Harvey Williams Cushing – the father of modern neurosurgery – who popularized his training and surgical techniques throughout North America.

Halsted’s lasting influence on modern residency programs

Glenn Bandiera, executive director of standards and assessment at the Royal College of Physicians and Surgeons of Canada, said the structure of residency programs has changed dramatically over the years, from largely unstructured apprenticeship-type experiences to very structured, time-limited educational programs.

“Each residency program is based on this idea of ​​hierarchical responsibility,” he explains, “where residents gradually have increasing autonomy and accountability throughout their training.”

While that concept, rooted in Halsted’s pyramid training model, persists in today’s residencies, it is no longer as serious a program as when Halsted designed it. There was no guarantee in his model that residents would reach the top of his pyramid and complete their training.

“It’s fairly well accepted that once you’re in a residency position, you’re stuck in that program until you graduate. So the idea that there are people who can’t succeed in it is relatively rare in Canada.”

While residency programs have evolved rapidly since Halsted was training budding doctors at Johns Hopkins, Bandiera said some of his core principles have proven fundamental to medical practice.

“The idea that hospitals needed to provide 24/7 care to patients and that hospitals themselves were both a work environment and a learning environment, and that residents and other learners had to spend a lot of time practicing their craft to become experts – all of these have proven true.”